A full day will consist of actively seeing patients during their complete stay in the Emergency room or other line of practice along with the attending physician. The scribe will document everything step of the way from patient history of current illness all they way down to specific risk factors that could lead to a specific diagnosis. Multiple reassessments are done, and it is our job to document each physician-patient contact with accurate updates on patient status until the final disposition.
This is a multi-pronged question and depends on what specialty you are assigned to but the general idea is the same. The medical scribe works in a fast paced environment where most of the time you are standing or moving while working in the electronic medical records (EMR). When transcribing in the EMR, it is important to use the language and medical terminology that a physician would use. Prior to the physician’s arrival, the scribe arrives early and preps the charts for the patients for that day, either consults or follow-up appointments. The medical scribe accompanies the physician into the patient exam room in order to transcribe a history and physical exam, in addition to documenting the physician’s encounter with the patient and family. They also document diagnoses and symptoms as well follow up instructions and prescriptions. The medical scribe also transcribes patient orders including laboratory tests, medical imaging, and chemotherapy. They also can be responsible for sending and receiving confidential faxed documents.
A day in the life can range from either smooth to really rough. I work in the ER, but there are other offices for example Cardiology or an Orthopedic office. You see various amount of pathology in the ER ranging from acute to chronic diseases. Some days you will see 15 patients, other days you can see up to 30-35 patients. Some days you will see codes, strokes, STEMI's, or many other different cases. You definitely have to have a stomach for the things you may see. Charting is a skill. I've encountered many times when I had to help either the doctor or the resident find their way in the chart. Most times than none, you are needed very much.